Application for Work Permit

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APPLICATIONFORWORKPERMITDateof application_____________________________ _________Certificate/Permitnumber_______ _________________________PDE 4565(1/13) minorSex_____________________________Col orof hair _____________________Colorof eyes____________________Signatureof issuingofficerAny physicalworkrestrictionsSchooldistrict nameand addressPlaceof residencePlaceof birthDateof birthEvidenceof age acceptedand requiredin the all but the one Transcriptof transcriptc. Passportd. parentor guardianaccompaniedbyphysician'sstatemen tof opinionas to theage of the minorMonth Day ,unlessminoris a highschoolgraduate(pleaseattachproofofgr aduation)Signatureof parent,guardianor legalcustodian*Nameand addressof parent,guardianor legalcustodianCommonwealthof Pennsylvania Departmentof education *In lieu of signatureunderclause(B), the applicantmay executea statementbeforea notarypublicor otherpersonauthorizedtoadministeroathsat testingto the accuracyof the factsset forthin the applicationon a formprescribedby the attachedto the Application .

Commonwealthof Pennsylvania ‐Department of Education *In lieu ofsignature under clause(B),the applicant mayexecute a statement before a notary public orother person authorizedto administeroathsattesting to the accuracyofthe factsset forthin the application ona form prescribed by the department. The statement shall be attached to the application.

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